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ORIGINAL ARTICLE
Year : 2013  |  Volume : 50  |  Issue : 4  |  Page : 345-348
 

Challenges in management of phyllodes tumors of the breast: A retrospective analysis of 150 patients


Department of Endocrine and Breast Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication24-Dec-2013

Correspondence Address:
P Ramakant
Department of Endocrine and Breast Surgery, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.123625

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 » Abstract 

Introduction: Phyllodes tumors (PT) of the breast seem to get pre-operatively misdiagnosed as fibroadenomas resulting in inadequate resections and high local recurrence rates. Materials and Methods: Data of 150 patients with PT of the breast managed from January, 2003 to February, 2013 were retrospectively analyzed. Statistical analysis performed using SPSS version 17 (Pearson Chi-square test and analysis of variance test for analysis). Aim: The aim of this study is to compare clinico-pathological profile and recurrence rates in patients with benign (B), borderline malignant (BL) and malignant (M) PT. Results: In a total of 150 patients with PT (n = 77 B, n = 24 BL, n = 49 M), mean age was 36.92, 44.04 and 40.46 years respectively (P 0.015) and mean tumor size being 8.15 cm, 14.7 cm and 12.9 cm respectively (P 0.000). Pre-operatively cytology suggestive of PT in 24% patients with B PT and 63% in M PT; core tissue biopsy suggestive of PT in 85.4% patients with B PT and 100% in M PT. Recurrence seen in 34.7% out of which 32.7% were post-lumpectomy performed elsewhere. Majority of B PT had lumpectomy (49.3%)/wide local excision (WLE, 31.2%) compared with M PT where 55.1% had simple mastectomy (SM) due to large tumor size. Local recurrence was more in M PT (53%) compared with B PT (20%). We found recurrence rates in L (39.3%) compared with WLE (27.3%) and SM (33.9%) (P 0.049). Conclusions: Larger tumor size, incomplete resection and M/BL histology predicted higher recurrence in PT. Core biopsy is much more accurate than fine needle cytology in the diagnosis.


Keywords: Local recurrences, malignant phyllodes, phyllodes tumors of the breast, radiation therapy


How to cite this article:
Ramakant P, Chakravarthy S, Cherian J A, Abraham D T, Paul M J. Challenges in management of phyllodes tumors of the breast: A retrospective analysis of 150 patients. Indian J Cancer 2013;50:345-8

How to cite this URL:
Ramakant P, Chakravarthy S, Cherian J A, Abraham D T, Paul M J. Challenges in management of phyllodes tumors of the breast: A retrospective analysis of 150 patients. Indian J Cancer [serial online] 2013 [cited 2020 Feb 17];50:345-8. Available from: http://www.indianjcancer.com/text.asp?2013/50/4/345/123625



 » Introduction Top


Phyllodes tumors (PT) of the breast are known for local recurrence especially when lumpectomy (L) is performed for a suspected fibroadenoma in a misdiagnosed PT. The most common reason for missing a diagnosis of PT especially in small tumors is that they are often confused with fibroadenomas and fine needle aspiration cytology (FNAC) does not clearly help in differentiating fibroadenoma from PT. [1] Core tissue biopsy plays a key role in making a correct pre-operative diagnosis of PT. PT can be benign (B), borderline malignant (BL) and malignant (M). Wide local excision (WLE) is standard of care for all the histological subtypes of PT. [2] We aimed to study factors predicting recurrence rates in all cases of PT. We also performed a detailed analysis to compare the clinic-pathological profile in all the three histological subtypes of PT.


 » Materials and Methods Top


We retrospectively analyzed data of 150 patients with PT of the breast that were surgically managed during January, 2003 to February, 2013. The clinical details of presentation, operation records and histology were recorded. Statistical analysis was performed using SPSS version 17 (Pearson Chi-square test for analysis). Analysis of variance test was applied to find out statistical significance in mean values in the three histological subtypes of PT.


 » Results Top


Out of total 150 patients with PT, 77 (51.33%) were B, 24 (16%) BL and 49 (32.67%) were M PT. The mean age in the whole cohort of patients was 39.24 years (range: 15-70 years), mean tumor size was 10.78 cm (range: 1-30 cm) and mean duration of presentation with a breast lump was 29.67 months (range: 1-276 months). Recurrent PT was seen in 34.7% (n = 52) out of which 32.7% (n = 49) presented as recurrence post-lumpectomy done elsewhere.

[Table 1] shows patient profile in B, BL and M subtypes of PT. BL and M subtypes had a slight preponderance of older age and larger tumor size compared with B subtype (P 0.015, P 0.000 respectively). Core tissue biopsy has now become standard of care in making a pre-operative diagnosis of PT and it was 100% accurate in M PTs. FNAC was not very helpful even in our series of patients with PT as only 24% could be correctly diagnosed with B PT.
Table 1: Patient profile


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[Table 2] shows details of the various surgical procedures performed in patients with PT. Majority of B PT had L (49.3%)/WLE (31.2%). However, 55.1% of M PT had simple mastectomy (SM). The very large tumor size in M PT led to higher frequency of SM which was performed with the intention of WLE in PT. Axillary lymph node dissection (ALND) was done in 26 patients and only one had positive nodal metastases and that also was from infiltrating duct carcinoma, in the rest all nodes were free from disease showing reactive hyperplasia. Patient with positive node had infiltrating ductal carcinoma (IDC) of the breast in adjacent breast tissue and also involving the PT. Reconstructive procedures were performed more frequently in M PT (n = 31.4%) compared with 10% in B and 12.5% in BL PT.
Table 2: Surgical details


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[Table 3] shows that local recurrence rates were higher in M PT (n = 26, 53.1%) and BL PT (n = 10, 41.7%) compared to B PT (n = 16, 20.8%) (P 0.000). Most (24/26) patients with M PT with recurrence presented to our out-patient clinic with 1 st time recurrence following a L done elsewhere.
Table 3: Recurrence rates


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We compared recurrence rates to type of surgical procedure and found recurrence rates in L (39.3%) compared to WLE (27.3%) and SM (33.9%) (P 0.049). We also compared the recurrent tumor status with initial surgical histology and noticed that 7 patients with B had B PT, 10 B had BL/M PT on recurrence and out of 7 M PT with recurrence 5 were M again and 2 were B on recurrence.

[Table 4] shows comparison of small (size <10 cm) and giant PT (size >10 cm). Giant PT has higher recurrence rates (41.1%) compared to smaller PT (29.3%). In B PT with size <10 cm, 20 patients were preoperatively thought to have fibroadenoma and underwent L and final histology was PT.

[Table 5] shows details of adjuvant therapy in the form of radiation therapy which was given in recurrent PTs (B PTs n = 5, BL PTs n = 9, M PTs n = 28). Chemotherapy was given in the adjuvant setting in 5 patients who had metaplastic carcinoma/IDC and 4 patients with distant metastases got palliative chemotherapy.
Table 4: Comparison of small and large phyllodes tumors in terms of recurrence rates


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Table 5: Adjuvant treatment


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Distant metastases were seen in 4 patients with M PTs. Three patients had lung metastases (one also had brain metastases) and one had skeletal metastases. In all these patients with metastatic disease, histopathology showed combination of metaplastic carcinoma, IDC or osteosarcomatous component along with M PT. One patient with lung and brain metastases died 3 months after surgery while on palliative chemotherapy.


 » Discussion Top


PTs of the breast have been associated with diagnostic dilemma since their original description. With a better understanding of the clinic-pathological profile even the nomenclature changed from cystosarcoma phyllodes to "PT." [3] These biphasic tumors of the breast can be B, BL or M. In our series, we had 51.33% B, 16% BL and 32.67% M PT which is comparable with the available literature. [4] Although most PTs are B (Tan et al. showed up to 74% as B PT in their series) yet due to inadequate resections they recur locally and result in re-excisions, which can be avoided by WLE. [4] Hence WLE is standard of care, but in larger tumors and recurrent giant PTs the surgical extent needs to be tailored and some may even need reconstruction for closure or for cosmesis. [5]

In PT, both small and a large tumor sizes have been associated with problems in management of such tumors. In our series, we found mean tumor size was larger in BL/M PT compared to B PTs. This may be due to delayed presentation and longer duration of lump. The mean duration of presentation in our patients were 25.4 months (range: 1-156 months) in B, 51.38 months (range: 1-276 months) in borderline and 25.75 months (range: 1-240 months) in M PTs. This reflects lack of awareness, socio-economic problems and hesitations due to personal/family reasons among our patients before they decide to consult a surgeon.

Small PTs tend to get confused with fibroadenomas and have high recurrence rates post-lumpectomy. Larger sized or giant PT (>10 cm) have a higher malignancy rates (42.5%) and higher recurrence rates (41%) compared with smaller tumors (21% malignancy and recurrence rates 29%) and hence need more aggressive management protocols and adequate resection margins even post-mastectomy.

In our patient series, in the earlier years we had more lumpectomies for B PT as they were misdiagnosed as fibroadenomas on basis of cytology alone. Hence, with time, our practices have changed to do core tissue biopsy in any breast lump larger than 3 cm size or any clinical/radiological suspicion of PTs irrespective of size. Hence, in our series, patients with B PT had L (L) (49.3%)/WLE (31.2%). However, 55.1% of M PT had SM due to larger tumor size occupying almost the whole breast. Intra-operatively, whenever we felt large firm palpable nodes we did axillary dissection in few patients with M PTs but now on the basis of our results we have stopped doing it unless it is proven with metastases.

Malignancy rates increase with increasing age of patients. [6] Even in our series, we found patients with M/BL PTs had a mean age of 40-44 years, which was more compared to B PTs. Hence, when we see larger PTs in older age group patients, we must suspect and rule out malignancy by doing a thorough clinical examination and core tissue biopsy.

Pre-operative correct diagnosis of PT is always a challenging task for surgeons and also for pathologists. FNAC has a low sensitivity of up to 60% in correctly diagnosing PT. [7] In our series, accuracy of FNAC in diagnosing PT was more in M PT (63%) compared to 24% in B PTs. Core tissue biopsy has played a very vital role in histological assessment of PT in pre-operative setting and in differentiating PT from cellular fibroadenomas. This has helped in correct surgical planning, reducing the number of unnecessary reoperations for post-lumpectomy local recurrences and morbidity. The sensitivity of core tissue biopsy in diagnosing M PT is as high as 99%. [8] Even in our series, core tissue biopsy was 100% accurate in diagnosis in M PTs compared with 85.4% in B PTs. In cytology, it is difficult to differentiate between B PT and cellular fibroadenomas resulting in poor yield of diagnosis. Even in our patient series, on the basis of cytology, we could diagnose correctly in only 24% patients. Cytology could detect M PTs in 63% of our patients due to characteristic M features. Hence, we recommend core tissue biopsy in pre-operative setting to avoid any delay in diagnosis.

Imaging also has a role to play in detecting PT and differentiating it from fibroadenomas. The ultrasonographic features suggesting a PT are heterogeneity, hypoechoic mass with lobulations and irregular margins compared to fibroadenomas, which appear as circumscribed, homogeneous, oval, hypoechoic masses with a smooth, echogenic capsule. [9]

Radiation therapy has been advocated to minimize local recurrence rates especially in recurrent tumors, tumors with close margins or M PTs. [10],[11]

In the literature, in PT, local recurrence rates have been found to be up to 30-65% and are higher in BL and M PT. [12],[13] L in M PT has been associated with high recurrence rates up to 65% compared to WLE with 35% recurrence rates. [14]

The role of ALND is controversial in M PT. In the literature we have conflicting views. 10% of patients may present with clinically significant axillary lymphadenopathy, but hardly <1% may be positive on histology and IDC of breast co-existing with PT may also result in positive lymph node metastases. [15],[16],[17] Even in our data, out of 26 patients only one with IDC along with PT had positive nodes in ALND specimen, which was reported metastatic from the intraductal cancer and not from M PT. Hence most of the time enlarged nodes are due to reactive hyperplasia and dissection may be avoided.

Recurrent tumor histotype may or may not be similar to the primary tumor. M transformation has been found occasionally in PT. [18] Even in our series, we found 10 patients with B PT had M component in recurrence.

Asoglu et al. have shown in their series of 50 patients with M PTs, distant metastases up to 26% and mortality of 32% in those patients. [19] In our series, we had four patients with distant metastases and one patient with lung and brain metastases died 3 months post-surgery while on palliative chemotherapy.


 » Conclusions Top


Giant PT of the breast, incomplete resection and M/BL histology predicted higher recurrence rates in PT. Recurrence is high when L is performed in undiagnosed cases. Core biopsy is much more accurate than fine needle cytology in the diagnosis. The role of core biopsy as a simple, effective out-patient procedure cannot be overstated in avoiding inappropriate initial surgery and surgeons are exhorted to avail of this diagnostic modality more frequently. ALND may be avoided in the vast majority and may be considered in the rare patient with significant proven metastatic nodes. Adjuvant radiation therapy may be advisable in recurrent tumors or large M tumors with close margins.

 
 » References Top

1.Bandyopadhyay R, Nag D, Mondal SK, Mukhopadhyay S, Roy S, Sinha SK. Distinction of phyllodes tumor from fibroadenoma: Cytologists' perspective. J Cytol 2010;27:59-62.  Back to cited text no. 1
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4.Tan PH, Jayabaskar T, Chuah KL, Lee HY, Tan Y, Hilmy M, et al. Phyllodes tumors of the breast: The role of pathologic parameters. Am J Clin Pathol 2005;123:529-40.  Back to cited text no. 4
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6.Ben Hassouna J, Damak T, Gamoudi A, Chargui R, Khomsi F, Mahjoub S, et al. Phyllodes tumors of the breast: A case series of 106 patients. Am J Surg 2006;192:141-7.  Back to cited text no. 6
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7.Foxcroft LM, Evans EB, Porter AJ. Difficulties in the pre-operative diagnosis of phyllodes tumours of the breast: A study of 84 cases. Breast 2007;16:27-37.  Back to cited text no. 7
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8.Komenaka IK, El-Tamer M, Pile-Spellman E, Hibshoosh H. Core needle biopsy as a diagnostic tool to differentiate phyllodes tumor from fibroadenoma. Arch Surg 2003;138:987-90.  Back to cited text no. 8
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9.Chao TC, Lo YF, Chen SC, Chen MF. Sonographic features of phyllodes tumors of the breast. Ultrasound Obstet Gynecol 2002;20:64-71.  Back to cited text no. 9
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10.Chaney AW, Pollack A, McNeese MD, Zagars GK. Adjuvant radiotherapy for phyllodes tumor of breast. Radiat Oncol Investig 1998;6:264-7.  Back to cited text no. 10
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11.Pezner RD, Schultheiss TE, Paz IB. Malignant phyllodes tumor of the breast: Local control rates with surgery alone. Int J Radiat Oncol Biol Phys 2008;71:710-3.  Back to cited text no. 11
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12.Barth RJ Jr, Wells WA, Mitchell SE, Cole BF. A prospective, multi-institutional study of adjuvant radiotherapy after resection of malignant phyllodes tumors. Ann Surg Oncol 2009;16:2288-94.  Back to cited text no. 12
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13.Tan EY, Tan PH, Yong WS, Wong HB, Ho GH, Yeo AW, et al. Recurrent phyllodes tumours of the breast: Pathological features and clinical implications. ANZ J Surg 2006;76:476-80.  Back to cited text no. 13
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19.Asoglu O, Ugurlu MM, Blanchard K, Grant CS, Reynolds C, Cha SS, et al. Risk factors for recurrence and death after primary surgical treatment of malignant phyllodes tumors. Ann Surg Oncol 2004;11:1011-7.  Back to cited text no. 19
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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